10 top tips in thyroid surgery - academia.cat · thyroid lobect. omy is the minimum...
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10 Top Tipsin Thyroid Surgery
Ricard Simo FRCS (ORL-HNS) PhD
Consultant Otorhinolaryngologist Head, Neck and Thyroid Surgeon
Guy’s and St Thomas’ Hospital NHS Foundation Trust
London
United Kingdom
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Conflicts of InterestNone to declare
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Claudius Galen
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Historical Background
Abu Al-Qasim (El-Zahra 936-1013) in Al-Tasrif 952 AD “First goitre excision”
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Historical Background
• Diffenbach 19th Century – “One of the most thankless, most perilous undertakings which if not altogether prohibited, should at least be restricted”
• Gross US - Thyroid surgery is a “horrid butchery…deserving of rebuke and condemnation, and that “no honest and sensible surgeon ever engage in it”
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The European MastersTheodor Billroth (1829-1894)
-Tetany and no myxoedema -Theodor Kocher (1841-1917)- Myxoedema but no tetany -
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William Halstead (1852-1922)
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Tip 1
Know your anatomy and your embriology!
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Embriology
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Surgical Anatomy
• Skin• Subcutaneous fat• Investing cervical fascia• Strap muscles• Thyroid gland• Vascular structures• RLN/SLN• Parathyroids• Trachea• Thyroid cartilages
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Surgical Anatomy
Fascial Neck Spaces
• Superficial Fascia• Deep Cervical Fascia
– Investing fascia– Pre-vertebral fascia– Pre-tracheal Fascia– Carotid Sheath
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Surgical Anatomy
• Vascular supply– STA from ECA– ITA from TCT– STV– MTV– ITV
• Neural structures– Recurrent Laryngeal
Nerve– External Branch Superior
Laryngeal Nerve
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Tip 2
Know your indications and be precise on the extent
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Aim of thyroid surgery
• Resolution of the pathology– Total thyroidectomy– Near-total thyroidectomy– Thyroid lobectomy with isthmusectomy– Subtotal thyroidectomy!!!!
• Minimal complications– RLN and EBSL– Parathyroid glands
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Management Principles
• Adequate excision of gross tumour• Preservation of functioning structures – allowing
breathing, swallowing and phonation• Preservation of vital structures• Use of adjuvant therapies
Patel and Shaha 2005, British Thyroid Association 2014, ATA Guidelines 2012
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Does the patient needs the surgery?
Will the patient benefit from the surgery?
Which would be the optimal extent of the surgery?
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Surgery for thyroid nodules
Thy 3f: Bethesda 3 and 4 - Follicular Thyroid Neoplasm
• 29% of Thy 3 are cancers• “Diagnostic” Total lobectomy with
isthmusectomy• Level VI exploration• Identification & preservation of RLN• Identification & preservation Parathyroid
glands• The diagnostic lobectomy should be
therapeutic.Tysome el al BJS 2009
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Solitary Thyroid Nodule
Thy 4: Bethesda 5 - Suspected Malignancy
• Lobectomy – STN less than 3 cm in low risk patients and negative USS of contralateral lobe
• Lobectomy with frozen section and proceed – Sensitivity 20%• Total thyroidectomy – Multinodular goitres with compression symptoms and high
risk patientsPang et al Sub to Clin Oto
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Multinodular Goitre
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Thyroid Carcinoma
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Thyrotoxicosis
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Tip 3
AccuratePreoperative Planning
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Preoperative Check List
Thyroid function test and antibodiesCytology/Histology
Imaging
Seen patient yourselfInformed consent
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Preoperative Evaluation
Essential
• TFT, Thyroid antibodies
• USS guided FNAC/CNB
• CT Scan• Magnetic Resonance Scan• PET-CT
Patel and Shaha 2005, Czaja McCaffrey 2006, Seo et al 2010
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Preoperative Evaluation
Pre-operativefibreoptic laryngoscopy
• Essential• Provides a dynamic view• Essential medico-legal
investigation• Direct laryngoscopy if laryngo-
tracheal invasion is suspected
Jeannon and Simo 2009, Czaja McCaffrey 2006
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Ultrasound Guided FNAC Evaluation
Patel and Shaha 2005, Czaja McCaffrey 2006 BAETS 2014
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Cross Sectional Imaging – CT or MRI
– Staging investigations– Thyroid cancer – MNG with compression symptoms and intrathoracic
extension
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Multiplanar CT
• CT with multiplanar views – Tri-dimentional views• With contrast except when patients have allergy to iodine
contrast• Predictor of surgical approach
Huins et al, Int J Surg 2007,Pollard et al Am J Neuroradiol 2005,Grainger et al ORL H&N Surg 2005
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Preoperative Evaluation
• Multidisciplinary Team approach essential• Dedicated and experienced surgical team• Thoracic, Plastics and UGI teams available
Simo and Jeannon 2009, Czaja McCaffrey 2006, Patel and Shaha 2005
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Tip 4
Have up to date Surgical aids available and use them regularly
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Surgical Aids
• Use of neuromonitoring• Surgical Loopes• Micro-instruments• Powered Instruments – Haemostatatic devices and
microdebrider
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Surgical Aids
• Don’t start using them with the difficult case• Ensure that you have received adequate
training• Troubleshooting • Use them all the time
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Tip 5
Plan carefully and be precised with your incisions as you will be
remembered for it
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Thyroidectomy
• Incision
• Kocher incision. Transverse incision half-way through sternal notch and cricoid cartilage
• Follow the tension lines
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No excuse for a bad scar ?
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Spot the difference! • MIT – 2.5 cm• 23h stay• TTO’s CP and Paracetamol• Scar satisfaction: Excellent
• Conventional 4 - 5 cm• 23h stay• TTO’s CP and Paracetamol• Scar satisfaction: Excellent
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Patient Expectation 2019
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Patient Expectation 2019
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Tip 6
Don’t be conservative with your approach
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Thyroidectomy
Approach
• Subplatysmal flaps elevated
• Incision cervical fascia• Strap muscles identified,
retracted or divided in the superior third
Space and view is essential
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Don’t forget the Pyramidal Lobe!
• Common pitfall
• May need chasing to hyoid bone
• Beware of subclinical thyroglossal duct cysts
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Tip 7
Be systematic with the Superior Vascular Pedicle
and EBSLN
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Thyroidectomy
Division Vascular Pedicles
• Superior thyroid arteries and veins• Mid thyroid veins• Inferior Thyroid veins
• Individual vessels identified and mass ligations avoided
Decrease risk of post-operative haemorrhageDecrease risk of EBSLN injuryDecrease risk of leaving a thyroid remnant
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Superior Thyroid Pedicle
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EBSLN Injury
• The Nerve of Amelita Galli-Curci• Failure to produce high pitches
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Superior Laryngeal Nerve
Cernea’s Classification• Type 1: Nerve crossing 1 cm or above horizontal plane superior thyroid pole• Type 2a: Nerve crossing less than 1cm above plane• Type 2b: Nerve below plane
Cernea et al Head and Neck 1992
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EBSLNType I: 60 to 68%Type II: 20%Type IIb: 14-20 %
í
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Tip 8
Be critical with the identification and the dissection
of theRecurrent Laryngeal Nerve
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Voice Outcomes
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Clinical Practice Guideline
Aim: To minimize risk and optimize outcome
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ATA
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Recurrent Laryngeal Nerve
• The nerve should always be identified
• The identification of the nerve may vary depending on the case
• Beware of individual nerve anatomy especially it’s relationship with the Inferior Thyroid artery
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Identification of RLNApproach Indications Advantages Disadvantages
Lateral Approach Uncomplicated cases
Protection vascular supply Parathyroid Glands
Not available in cases of large goitres or revision surgery
Inferior Approach Revision or large goitres
Identifies the nerve in a virgin site
Long segment dissected may lead to neuropraxia
Superior Approach Revision, large goitres, when considering non-RLNFailure of other approaches
RLN most constant Ligament of Berry may bleed
Randolph G et al World J Surg 2004
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RLN – Lateral Approach
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RLN - Inferior Approach
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RLN - Superior Approach
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RLN Superior Approach
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Recurrent Laryngeal Nerve
• Extra-laryngeal branching - 30%
• Non-recurrent laryngeal nerve - 1%
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Tip 8
Identify and preservethe
parathyroid glands – at least 2!
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Thyroidectomy – Parathyroid Glands
• The PT glands should be identified whenever possible
• 25 % the PT glands are not in the normal location
• Whenever the vascular supply is lost, do a frozen section and re-implant the gland in the SCM
• Autotransplantation?
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Parathyroid Glands and RLN
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Tip 9
Don’t forget the Berry’s Ligament
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Berry’s Ligament
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Thyroidectomy
Berry’s Ligament
• Very careful dissection• Bipolar diathermy at low
voltage 8 to 10 volts• Use knife – 15 size blade• Avoid mass ligations• You may need to leave a
remnant to protect the nerve especially if the crico-tracheal grove is deep.
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Tip 10
And finally don’t forget to close properly!
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Total Thyroidectomy with CND
Jeannon and Simo 2009, Patel and Shaha 2005
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Thyroidectomy
Closure
• Haemostasis (Valsalva)• Saline wash• Check RLN and PT
glands• Drain?• Closure in layers
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Summary
• Thyroidectomy is not an easy operation• Surgeons should be highly trained and capable to
deal with any variations of the disease process and apply adequate surgical procedures.
• Preoperative planning should never be understimated
• The technique requires meticulous attention to detail and the identification and preservation of RLN, EBSLN and parathyroid glands
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Summary
• Thyroid lobectomy is the minimum “diagnostic” and therapeutic procedure
• Total thyroidectomy is still the definitive procedure for the majority of thyroid disorders and specially cancer.
• Use current technology to aid your surgery
• New minimally invasive techniques should be addressed with caution.
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